‘Ignorance is not bliss’ explained Dr. Wulf H. Utian as he started his session at EMAS 2019. And when it comes to menopause, truly the more information the better. Over the decades, we have seen a real shift in the understanding of menopause by women, clinicians and in wider society. Understanding of treatments too has also developed, albeit not always smoothly.
1950s - 1960s
The negative connotations of menopause have been recognised since the 1700’s. However, it wasn’t until the 1950’s that hormone replacement therapy (HRT) was first developed in order to treat menopausal symptoms.
In the 1960s, many promises were made to women over how HRT may benefit them. In the 1996 publication ‘Feminine Forever’, Robert Wilson stated:
‘For the first time in history, women may share the promise of tomorrow as biological equals of men. Specifically, they can remain able and active in mind and body for their entire life. Thanks to hormone therapy, they may look forward to prolonged well-being and extended youth’.
This was widely believed at the time, however a true understanding of the efficacy of HRT was still to be demonstrated.
1980s - 1990s
Between the 1980s and 1990s, observational data and clinical experience started to indicate estrogen therapy as effective for decreasing risk of coronary heart disease (CHD) and hip fracture. 
The PEPI and HERS trials built on this knowledge, providing an understanding that while HRT was effective for the primary prevention of CHD, it was not effective for secondary prevention of CHD. [2,3]
Dr. Andrea Genazzani explained that since 1995, breast cancer risk was also identified as related to HRT. However, even at this time it was clear that the risk was not associated with estrogen. Instead the risk was only related with certain types of progesterone.
2000s - Today
In 2002, Mosca et al concluded that they key to using HRT for prevention of CHA may be to target therapy before atherosclerosis is evident, and to identify women with genetic susceptibility who may be at increased risk for an adverse outcome associated with the therapy. 
Also published in 2002 was the Women’s Health Initiative (WHI) study, which suggested that the risks of HRT often outweighed its benefits.  Despite an immediate response by the British Menopause Society, International Menopause Society and others who considered the study flawed, there was a 63% total reduction in HRT prescription.
As a result of the WHI study, many women were deprived of a good therapeutic option for menopausal symptoms. Finally, 18 years later, follow-up data was published to recognise that no elevations in all-cause mortality were found in those taking HRT. 
During this time, understanding of HRT developed further, with more research conducted to demonstrate the importance of timing intervention and personalising treatment for each patient. 
Research into menopause and symptoms of the menopause is far from over! New concepts are being investigated including the dynamics of the aging process, the role of steroids in physical and mental aging as well as andropause and the role of androgen in menopause. There is certainly an exciting future ahead.
 Grady D, Rubin SM, Petitti DB, et al. Hormone Therapy To Prevent Disease and Prolong Life in Postmenopausal Women. Ann Intern Med. 1992;117:1016–1037. doi: 10.7326/0003-4819-117-12-1016
 Greendale GA, Reboussin BA, Hogan P, et al. Symptom relief and side effects of postmenopausal hormones: results from the Postmenopausal Estrogen/Progestin Interventions trial. Obstet Gynecol 1998;92: 982-988.
 Hulley S, Grady D, Bush T, et al. Randomized Trial of Estrogen Plus Progestin for Secondary Prevention of Coronary Heart Disease in Postmenopausal Women. JAMA. 1998;280(7):605–613. doi:10.1001/jama.280.7.605
 Ho JE, Mosca L. Postmenopausal hormone replacement therapy and atherosclerosis. Curr Atheroscler Rep 2002;4:387–95.
 Rossouw J. E., Anderson G. L., Prentice R. L, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. Jama. 2002;288:321–33.
 Manson JE, Aragaki AK, Rossouw JE, et al. Menopausal Hormone Therapy and Long-term All-Cause and Cause-Specific Mortality: The Women's Health Initiative Randomized Trials. JAMA. 2017;318(10):927–938. doi:10.1001/jama.2017.11217
 Harman SM, Brinton EA, Cedars M, et al. KEEPS: The Kronos Early Estrogen Prevention Study. Climacteric 2005;8:3–12